Provider Demographics
NPI:1568900116
Name:MAPLE LAKE ACADEMY FOR BOYS
Entity Type:Organization
Organization Name:MAPLE LAKE ACADEMY FOR BOYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARGO
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-798-7700
Mailing Address - Street 1:6612 S 3200 W
Mailing Address - Street 2:
Mailing Address - City:BENJAMIN
Mailing Address - State:UT
Mailing Address - Zip Code:84660-4123
Mailing Address - Country:US
Mailing Address - Phone:801-798-7700
Mailing Address - Fax:
Practice Address - Street 1:6612 S 3200 W
Practice Address - Street 2:
Practice Address - City:BENJAMIN
Practice Address - State:UT
Practice Address - Zip Code:84660-4123
Practice Address - Country:US
Practice Address - Phone:801-798-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-03
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT18290323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility